Failure to Prevent Unnecessary Psychotropic Medication Use
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary psychotropic medications and chemical restraints. The resident, who had a history of generalized anxiety disorder, major depressive disorder, and advanced dementia, was observed to be confused and unable to answer questions appropriately. Upon review, it was found that the resident's psychotropic medication doses were increased and new medications were added without adequate supporting documentation or clear evidence of behaviors warranting such changes. There was also a lack of consistent and detailed monitoring of the resident's behaviors and the effectiveness of non-pharmacological interventions. The clinical records and medication administration records revealed that behavior monitoring for psychotropic medication use was not initiated upon admission and was delayed for several months. Documentation of behaviors was sporadic and inconsistent between nursing and CNA records, with many instances lacking detail or correlation. Additionally, there was no documentation from the psychiatric nurse practitioner for the dates when medication increases were ordered, and progress notes often did not align with the reported behaviors or medication changes. The facility's own policy required initiation of behavior monitoring and documentation of non-medication interventions, which was not followed. Interviews with the medical director and psychiatric nurse practitioner indicated that decisions regarding medication increases were based on staff reports of behaviors, but these reports were not substantiated in the resident's clinical record. There was also no evidence that gradual dose reductions were attempted or considered, as required by facility policy. The lack of supporting documentation, inadequate monitoring, and failure to attempt dose reductions led to the resident receiving unnecessary psychotropic medications.